INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted April 9, 2026, by staff from the Bureau of Program Licensure. Based on the findings of the on-site investigation, Pottstown Comprehensive Treatment Center was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of patient charts, the facility failed to review and update the treatment and rehabilitation plans at least every 60 days in three out of three applicable charts reviewed.
Patient 1 was admitted on 12/11/2018 and was a current patient at the time of the investigation. The most recent treatment plan update was dated 10/11/2025. Treatment plan updates were not completed 12/11/2025 and 2/11/2026.
Patient 2 was admitted on 2/2/2024 and was a current patient at the time of the investigation. The most recent treatment plan update was dated 12/2/2025. Treatment plan updates were not completed 2/2/2026 and 4/2/2026.
Patient 3 was admitted on 1/23/2024 and was a current patient at the time of the investigation. The most recent treatment plan update was dated 1/15/2026 and 10/25/2025. Treatment plan updates were not completed 12/26/2025 and 3/16/2026.
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Plan of Correction
The Clinic Director met with the Clinical Supervisor to review regulation 709.92(b). Treatment plan updates will be completed timely based on patients level of care and needs, with the minimum being every 60 days. The Clinical Supervisor will review the services due report in SMART with each of their reports daily during the end of day process with weekly reviews during supervision using the weekly time frame. Areas requiring additional attention will be discussed and documented during regular clinical supervision. CS will review with counseling staff due dates daily to ensure compliance. Adherence to this regulation was presented and reviewed during with all counselors during group clinical supervision on April 29, 2026. Further, compliance in this area will also be reviewed by the Clinical Supervisor during all Quality Record Reviews. Non-compliance in this area will be documented in writing and employee improvement plans will be presented if warranted. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of patient charts, the facility failed to assure that counseling services are provided according to the individual treatment and rehabilitation plan in two out of three applicable charts reviewed.
Patient 1 was admitted on 12/11/2018 and was a current patient at the time of the investigation. The most recent treatment plan update dated 10/11/2025 indicates that the patient will attend at least 2.5 hours per month of group or individual psychotherapy. Chart documentation showed that the patient received fewer psychotherapy than required in October 2025 (1.5 hours received), December 2025 (1.5 hours received), and February 2026 (15 minutes received).
Patient 2 was admitted on 2/2/2024 and was a current patient at the time of the investigation. The most recent treatment plan update dated 12/2/2025 indicates that the patient will receive 2.5 hours per month of group or individual counseling. Chart documentation showed that the patient received less than the recommended counseling in January 2026 (1.5 hours received) and February 2026 (1 hour received). Also, there was a blank group note dated 4/9/2026 in the patient chart which makes it unclear if those services were provided or not.
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Plan of Correction
The Clinic Director met with the Clinical Supervisor to review regulation 709.92(c). A more thorough review of patient files will be conducted to ensure that counseling staff are completing necessary paperwork and documentation in a timely manner. The continued utilization of the EMR will ensure that all documentation is met within allotted time frames necessary to meet this regulation. Adherence to this regulation was presented and reviewed with all counselors during group clinical supervision on April 29, 2026. During that same meeting, CTC clinical supervisor required that all counseling staff complete internal audits of patient electronic records on a weekly basis. Compliance will be reviewed with counselors during individual and group supervision. The Clinical Supervisor will monitor compliance in this area |
709.93(a)(8) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(8) Case consultation notes.
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Observations
Based on a review of patient charts, the facility failed to ensure a complete client record in two out of three applicable charts reviewed.
Patient 2 was admitted on 2/2/2024 and was a current patient at the time of the investigation. The 2/2/2026 case consultation was missing from the patient chart.
Patient 3 was admitted on 1/23/2024 and was a current patient at the time of the investigation. The 2025 and 2026 case consultations were missing from the patient chart.
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Plan of Correction
The Clinical Supervisor will continue to conduct weekly and monthly reviews of all services due, utilizing the Services Due report via the EMR, including case consults. To ensure this regulation is met, review of this regulation was conducted by Clinical Supervisor with all counselors during group clinical supervision on April 29, 2026. Compliance to this regulation will be monitored monthly by Clinic Director.
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